Sunday, January 31, 2010


Regarding antidepressants:

Although the year is young, it has already brought my first moral dilemma. In early January a friend mentioned that his New Year's resolution was to beat his chronic depression once and for all. Over the years he had tried a medicine chest's worth of antidepressants, but none had really helped in any enduring way, and when the side effects became so unpleasant that he stopped taking them, the withdrawal symptoms (cramps, dizziness, headaches) were torture. Did I know of any research that might help him decide whether a new antidepressant his doctor recommended might finally lift his chronic darkness at noon?

The moral dilemma was this: oh, yes, I knew of 20-plus years of research on antidepressants, from the old tricyclics to the newer selective serotonin reuptake inhibitors (SSRIs) that target serotonin (Zoloft, Paxil, and the granddaddy of them all, Prozac, as well as their generic descendants) to even newer ones that also target norepinephrine (Effexor, Wellbutrin). The research had shown that antidepressants help about three quarters of people with depression who take them, a consistent finding that serves as the basis for the oft-repeated mantra "There is no question that the safety and efficacy of antidepressants rest on solid scientific evidence," as psychiatry professor Richard Friedman of Weill Cornell Medical College recently wrote in The New York Times. But ever since a seminal study in 1998, whose findings were reinforced by landmark research in The Journal of the American Medical Association last month, that evidence has come with a big asterisk. Yes, the drugs are effective, in that they lift depression in most patients. But that benefit is hardly more than what patients get when they, unknowingly and as part of a study, take a dummy pill—a placebo. As more and more scientists who study depression and the drugs that treat it are concluding, that suggests that antidepressants are basically expensive Tic Tacs.

Read it all.

I am actually not surprised by this. Don't get me wrong, antidepressants do work--the problem is in determining who might benefit from them and, under what circumstances.

My own theory is that, based on my reading of the literature (and about 30 years of clinical experience), that we physicians are prescibing antidepressants like lollipops--to anyone and everyone who expresses sadness that lasts for any length of time. The current Diagnostic and Statistical Manual (IV) instructs us not to diagnose "Major Depression" unless the period of sadness had gone on for > 2 months.

There is a debate raging right now in psychiatry as the newer criteria for the DSM V are being discussed. That debate has to do with how we clinicians distinguish between normal responses to stress, bereavement and trauma; and pathological responses.

This problem is perhaps best summed up in this excellent book by Allan Horowitz and Jerry Wakefield, which is appropriately titled, THE LOSS OF SADNESS: How Psychiatry Transformed Normal Sorrow into Depressive Disorder.

In The Loss of Sadness, Allan V. Horwitz and Jerome C. Wakefield argue that, while depressive disorder certainly exists and can be a devastating condition warranting medical attention, the apparent epidemic in fact reflects the way the psychiatric profession has understood and reclassified normal human sadness as largely an abnormal experience. With the 1980 publication of the landmark third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), mental health professionals began diagnosing depression based on symptoms--such as depressed mood, loss of appetite, and fatigue--that lasted for at least two weeks. This system is fundamentally flawed, the authors maintain, because it fails to take into account the context in which the symptoms occur. They stress the importance of distinguishing between abnormal reactions due to internal dysfunction and normal sadness brought on by external circumstances. Under the current DSM classification system, however, this distinction is impossible to make, so the expected emotional distress caused by upsetting events-for example, the loss of a job or the end of a relationship- could lead to a mistaken diagnosis of depressive disorder. Indeed, it is this very mistake that lies at the root of the presumed epidemic of major depression in our midst.

It is also very likely at the root of why many people only have a placebo response to antidepressants.

I had a rather long discussion last year with Dr. Wakefield about this very topic when I invited him to speak in Ann Arbor. The truth is that it is not only sorrow that tends to be pathologized by psychiatry, but other "diagnoses". And, until we can connect a psychiatric diagnosis with specific physiological anchors, the tendency is to pathologize everything that causes any degree of distress. This is considered compassionate and caring; but it has some important and long-lasting consequences; the most serious in my estimation, is in reinforcing a person's belief that the cause of their sad situation is "biological" and therefore outside of their control. This belief results in a tendency to ignore or minimize the psychological and psychosocial aspects of their situation, which they do have some control over.

ShrinkWrapped points out while discussing this same study:
The approval of Prozac in 1988 changed the entire field. Prozac, and the other SSRIs were far safer (almost impossible to use for a successful suicide attempt) and far easier to tolerate. With such a safety profile there was little reason to withhold such medications from patients who suffered from even mild Depression; to most people there was no downside. However, there has always been something missing in the reports on the efficacy of anti-depressants. Such medications are always given in the context of a relationship of the patient to the Doctor. Such therapeutic relationships have been recognized since antiquity as beneficial to the sufferer. Since Freud's day we have learned a great deal about the relationship and its impact on the people involved. Psychodynamic Psychotherapy is that treatment which mobilizes the unconscious aspects of the relationship in order to help the patient resolve previously poorly resolved conflicts. Such treatments are effective, though not for everyone, and offer long lasting benefits. [HT: NS]
Psychodynamic psychotherapy brings lasting benefits, new study finds
Psychodynamic psychotherapy is effective for a wide range of mental health symptoms, including depression, anxiety, panic and stress-related physical ailments, and the benefits of the therapy grow after treatment has ended, according to new research published by the American Psychological Association.

Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient's life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.

"The American public has been told that only newer, symptom-focused treatments like or medication have scientific support," said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. "The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last."

There are several reasons that there exists so much less empirical evidence for the efficacy of the Psychodynamic Psychotherapies. There exists no way for a large corporation to make money off of the dispensing of such treatment and therefore little incentive to actually perform the studies. Psychodynamic Psychotherapy also typically takes a longer time that Medication and the short term treatments (like CBT) to show its effects (though there is evidence that the benefits are deeper and longer lasting.)

The newer antidepressants are indeed safe; and these days they are rarely withheld when a person comes in to a mental health clinic complaining of depression--even if that depression has an obvious psychological or social etiology. But think about this: what if everyone who came into a medical clinic complaining of a scratch or cut was automatically started on powerful antibiotics? (BTW, part of the reason that antibiotics become less effective is because they are used so pervasively even in cases where they are not needed, thus strengthening the microorganism's resistance to them--that's where "super" infections come from). The truth is that many causes of prolonged sadness have to do with something in a person's life that is troubling them; or that they are reluctant to change (if they even consciously identify it).
For those who use anti-depressants as a way to numb their unhappiness and allow themselves to remain in unhappy conditions, when such drugs do their partial work, it can interfere with the person's' ability or interest in actually resolving the causes of their unhappiness. The lost opportunity costs of the SSRIs can be considerable.

In point of fact, the opportunity to learn and grow from one's losses in life; to become a more mature and (possibly) wise individual is lost; and instead the individual learns the lesson that he/she is a victim of their own biology; doomed to wander the earth during their lifetime always vulnerable to "stress" and knowing that they cannot cope with it on their own.

Again, there is real and devastating melancholy that seems to have no connection to the outside world; the inner world is irrevocably off-track and the person is unable to function. Biological studies of such individuals may bring us closer to understanding the pathological expression of sadness, where what is normal crosses a biological and physiological line and, without some biological treatment, can never get back on track (much like a real psychosis).

As Shrink says:
To put it into more Psychobiological terms, the human brain exists in a web of relationships with other human brains, all with multiple feedbacks affecting their functioning. Imagining we can tamper with the chemistry of our brains without regard to the interrelationships involved is an oversimplification that ultimately leads to unnecessary suffering.

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